The Delegated Welfare State and Policy Feedbacks

Chapter seven examines the impact of the MMA on politics, drawing upon original panel survey data to explore claims that market-based social provision can change mass attitudes about privatizing social programs. As the chapter shows, the new design of Medicare, with private entities providing the Part D and Medicare Advantage benefits, has not changed attitudes about the role of the state versus the market in health care, and nor has it undermined feelings of group consciousness and solidarity among seniors. Moreover, the Republican Party made few gains in ownership of issues like prescription drugs, Medicare, or health care in general after passage of the reform. However, the party did achieve “issue preemption,” in that it effectively solved the prescription drug issue and pushed it off the political agenda. The legislation also effectively demobilized the public around the prescription drug issue, offering a “good enough” policy that undercut efforts to improve the benefit or institute a directly governed alternative within Medicare. The MMA also created new constituencies protective of their programs. By demobilizing public demand for reform while also mobilizing commercial stakeholders, the MMA is generating a self-reinforcing logic that is difficult to challenge, absent unanticipated instability in the new Medicare marketplace or a fiscal emergency.